Hallux Valgus – 6 Fascinating Details, Signs, Causes, Prognosis and Therapy – rudms.com

Hallux Valgus – 6 Fascinating Details, Signs, Causes, Prognosis and Therapy


6 Fascinating Details of Hallux Valgus

  1. Hallux valgus is a typical progressive forefoot deformity consisting of lateral deviation of the hallux (huge toe) on the metatarsophalangeal joint accompanied by medial deviation of the primary metatarsal (metatarsus primus varus)
    • Nice toe angulates away from midline and towards different toes
    • Bony eminence at medial facet of first metatarsal head is known as a bunion
  2. Heredity and constricting footwear are thought of main contributing components
  3. Deformity could also be asymptomatic or end in foot ache and dysfunction
    • Ache sometimes positioned over bunion or beneath the lesser metatarsophalangeal joints
  4. Prognosis is predicated on scientific historical past, bodily examination, and radiographs
    • Radiographs help in deformity evaluation and remedy planning
  5. Therapy consists of conservative and surgical measures
    • Conservative remedy is the preferable first choice and should enhance signs and performance, however it doesn’t right the deformity
    • Many surgical process choices can be found; success is dependent upon selecting finest approach for a given deformity
  6. After acceptable surgical intervention, most sufferers are happy and have good scientific outcome
  • Hallux valgus is a typical progressive forefoot deformity consisting of lateral deviation of the hallux (huge toe) on the metatarsophalangeal joint accompanied by medial deviation of the primary metatarsal (metatarsus primus varus)
    • Nice toe angulates away from midline towards different toes
  • With development, the primary metatarsal head slides medially off the sesamoids
    • Bony eminence on the medial facet of the primary metatarsal head is known as a bunion
      • Thickening or irritation of the bursa overlying the primary metatarsal head can intensify this medial eminence

Scientific Presentation

Historical past

  • Scientific historical past of Hallux Valgus consists of period of signs, exercise modification, typical footwear selections, earlier interventions, historical past of foot trauma or arch collapse, and familial inheritance
  • Ache could also be current
    • Sufferers might complain of nice toe “pointing inward” (ie, laterally) towards different toes and inflicting:
      • Issue becoming desired footwear owing to deformity
      • Beauty considerations
    • Signs can embrace:
      • Ache
        • First metatarsophalangeal joint ache, soreness, or stiffness
          • Irritation of overlying bursa may cause ache over medial eminence
        • Ache could also be positioned beneath the lesser metatarsophalangeal joints
          • Malfunction of a given metatarsophalangeal joint might produce ache at one other metatarsophalangeal joint
        • Ache/strain underneath second or third metatarsals may result from switch metatarsalgia (ache at completely different ray than mechanically impaired ray)
        • Sometimes worse when sporting tight footwear or excessive heels and with weight bearing
      • Burning or numbness owing to compression of digital nerve

Bodily examination

  • Each naked toes examined in sitting and standing positions
    • Statement
      • Gait could also be antalgic or externally rotated
      • Alignment
        • Medial deviation of first metatarsal and lateral deviation of hallux
        • Pronation of hallux (nail faces medially)
      • Irritation and edema over medial eminence; ulceration could also be famous
      • Forefoot could also be extensive
      • Deformities of lesser toes, midfoot, or hindfoot
        • Stress of the nice toe towards the second toe might result in malalignment, subluxation, or dislocation of the second metatarsophalangeal joint
      • Thickened pores and skin over metatarsophalangeal joint and/or plantar floor (callus)
  • Palpation
    • Focal tenderness to palpation over medial eminence
      • Tenderness over dorsal hallux metatarsophalangeal joint might point out arthritic part
    • Tender plantar calluses point out switch lesions underneath the lesser metatarsophalangeal joints
      • Owing to shift in load-bearing capability from first ray (metatarsal, sesamoids, and hallux) throughout to lesser toes
  • Vary of movement
    • Decreased mobility of metatarsophalangeal joint
      • Energetic and passive vary of movement is assessed
        • With impartial place as recorded 0°, common passive dorsiflexion is 67°, and plantar flexion is 20° in adults aged over 45 years
      • Movement evaluated in lowered and nonreduced positions
        • Guide try to cut back deformity is made whereas gently dorsiflexing and plantar flexing the primary metatarsophalangeal joint; can decide diploma of correction which may be achieved
          • If movement is elevated in lowered place, it might counsel contracture of lateral tender tissues
          • If movement is decreased in lowered place, it might point out a change within the articular floor angle
          • If movement is restricted in lowered or nonreduced place, there could also be degenerative change
        • Ache or crepitus might point out degenerative adjustments
      • Toe pronation on extension can point out intrinsic malalignment
    • Hypermobility of first ray
      • Elevated laxity of the primary metatarsocuneiform joint might contribute to deformity
        • Examination carried out with ankle in impartial dorsiflexion
        • Second metatarsal head is stabilized with 1 hand whereas first metatarsal head is moved dorsomedially then plantar-laterally to gauge diploma of hypermobility; in contrast with contralateral facet
          • Grading could also be described as delicate, average, substantial mobility, and hypermobile
          • Approach has constant intrarater reliability, however little scientific objectivity evaluating magnitudes amongst examiners
      • The second metatarsophalangeal joint also needs to be examined
    • Ankle, subtalar, and transverse tarsal joints
      • Hindfoot deformity might contribute to improvement of forefoot points
        • Ankle joint: assessed by dorsiflexing and plantar flexing the foot at stage of ankle joint
          • Permits sagittal aircraft movement of 20° of dorsiflexion to 50° of plantar flexion alongside an axis working between ideas of the malleoli; marked variability between people
        • Subtalar joint: assessed by holding heel with palm of 1 hand, fingers on posterior heel; with different hand, the foot is inverted and everted
          • Vary of movement roughly 30° of inversion and 15° of eversion; magnitude variable between individuals
        • Transverse tarsal joint: evaluated by holding heel with palm of 1 hand, fingers on posterior heel; with different hand, the foot is kidnapped and adducted
          • Regular movement is roughly 20° of adduction and 10° of abduction
  • Peripheral vascular perfusion and motor/sensory operate are evaluated
    • Vascular occlusive illness can preclude surgical choices
    • Numbness or paresthesia over the dorsomedial distal phalanx may result from compression/irritation to dorsal cutaneous nerve overlying the bursa


  • Reason for hallux valgus is unsure however probably multifactorial, together with:
    • Intrinsic components
      • Genetic variations that end in altered biomechanics
      • Intercourse (extra frequent in females than in males)
      • Ligamentous laxity
      • Different foot deformities (eg, pes planus, pronated hindfoot, metatarsus primus varus)
      • Age (prevalence will increase with age)
      • Neuromuscular problems (eg, cerebral palsy, stroke)
    • Extrinsic components
      • Footwear (excessive heels, slender toe field)
        • Excessive heels improve forefoot loading; might exacerbate deformity
      • Extra weight bearing
  • Progressive deformity entails a number of steps, in live performance with predisposing components; usually a parallel course of quite than sequential
    • Begins with lateral deviation of nice toe and medial deviation of first metatarsal
    • Later phases contain progressive subluxation of the primary metatarsophalangeal joint
    • Bursa over joint thickens over time owing to strain of footwear on medial eminence

What will increase the chance of Hallux Valgus?

  • Prevalence will increase with age
    • Age of onset varies extensively
  • Impacts girls extra generally than males
    • Could also be related to extra slender, high-heeled footwear
  • Familial affiliation
    • 83% of sufferers have a constructive household historical past of hallux valgus deformities
Different danger components/associations
  • Tends to be bilateral
  • Different potential associations embrace:
    • Lengthy first metatarsal
    • Oval or curved metatarsophalangeal joint articular floor
    • Elevated first ray mobility
    • Achilles tendon tightness
    • Pes planus
    • Plantar gapping of first metatarsal cuneiform joint

How is Hallux Valgus recognized?

Major diagnostic instruments

  • Prognosis is by scientific historical past, bodily examination, and radiography
  • Acquire dorsoplantar and lateral weight-bearing radiographs for all sufferers with suspected hallux valgus
  • Further radiographic views could also be essential to assess deformity and help in remedy planning, however superior imaging is usually not needed


  • Weight-bearing dorsoplantar and lateral radiographs of the toes
    • 2 necessary angles are assessed to find out radiologic severity
      • Hallux valgus angle
        • Angle between lengthy axes of proximal phalanx and first metatarsal
      • Intermetatarsal angle:
        • Angle between lengthy axes of first and second metatarsals
    • Different angles which may be helpful in remedy planning embrace:
      • Distal metatarsal articular angle (10°-15°)
      • Hallux interphalangeus angle (regular angle lower than 10°)
  • Severity of hallux valgus may be categorized based mostly on standing anteroposterior radiographs
    • Regular
      • Hallux valgus angle: lower than 15°
      • Intermetatarsal angle: lower than 9°
      • Subluxation of lateral sesamoid on anteroposterior view: none
    • Gentle
      • Hallux valgus angle: lower than 20°
      • Intermetatarsal angle: 11° or much less
      • Lateral sesamoid subluxation: lower than 50%
    • Average
      • Hallux valgus angle: 20° to 40°
      • Intermetatarsal angle: lower than 16°
      • Lateral sesamoid subluxation: 50% to 75%
    • Extreme
      • Hallux valgus angle: better than 40°
      • Intermetatarsal angle: 16° or better
      • Lateral sesamoid subluxation: better than 75%
  • Different radiographic observations that may be helpful in guiding remedy embrace:
    • Varied different angular and positional relationships (eg, distal metatarsal articular angle, interphalangeus angle)
    • Metatarsal head form
      • Extra convex articular floor is extra vulnerable to hallux valgus deformity
    • Place of sesamoids relative to metatarsal head
      • Might show severity of deformity, diploma of pronation, and pathologic adjustments in sesamoids
    • Gapping of plantar facet of first metatarsocuneiform joint
    • Arthrosis of metatarsophalangeal joint
    • Metatarsus adductus
    • Presence of intermetatarsal aspect or os intermetatarseum
  • Further radiographs can embrace nonstanding lateral indirect views and axial sesamoid views
    • Axial sesamoid view might assist in figuring out extent of intrinsic malalignment
    • Might be helpful preoperatively

Differential Prognosis


  • Hallux rigidus
    • Osteoarthritis of the primary metatarsophalangeal joint
    • As with hallux valgus, signs embrace ache, stiffness, and swelling at first metatarsophalangeal joint
    • Differentiated by tender bump (bunion); if current, sometimes positioned on dorsal facet of metatarsophalangeal joint
      • Examination might present restricted and painful vary of movement, particularly dorsiflexion; crepitus could also be famous
    • Prognosis based mostly on bodily examination and radiographs (eg, sclerosis, subchondral cysts, joint house narrowing, osteophytes, dorsal bone spur)
  • Gout
    • Gout is a typical inflammatory arthritis brought on by deposition of monosodium urate crystals
    • As with hallux valgus, signs embrace ache, stiffness, and swelling at first metatarsophalangeal joint
    • Differentiated by comparatively acute onset of ache, redness, and swelling in joint
    • Prognosis based mostly on historical past, bodily examination, and laboratory testing
      • Definitive prognosis by joint aspiration
        • Diagnostic gold customary for gout is presence of negatively birefringent monosodium urate crystals in a synovial fluid pattern seen underneath polarized mild microscopy
      • Vital to distinguish from septic joint
  • Rheumatoid arthritis (Associated: Rheumatoid Arthritis)
    • An autoimmune illness; immune complexes inside synovial membrane trigger inflammatory response resulting in synovial thickening and joint destruction
      • Often impacts joints of the toes; hallux valgus is predominant foot deformity
    • Comparable signs embrace ache, swelling, and stiffness; ensuing deformities embrace bunions, claw toes, and metatarsalgia
    • Impacts a number of joints; sometimes each toes and related joints concerned (symmetrical)
    • Prognosis based mostly on scientific standards, laboratory outcomes (eg, ranges of rheumatoid issue, anticyclic citrullinated peptide; antinuclear antibody assays), and imaging options (eg, erosions, joint house narrowing)
  • Septic arthritis
    • An infection inside joint house; sometimes bacterial
      • Vital to think about in sufferers with acute joint illness
      • Can result in speedy, irreversible joint destruction; related to vital morbidity and probably deadly
    • Equally, presents with joint ache, redness, and swelling
    • Differentiated by comparatively acute symptom onset; fever could also be current
    • Prognosis instructed by scientific historical past, bodily examination, and laboratory testing (eg, WBC rely, erythrocyte sedimentation fee, C-reactive protein ranges)
      • Joint aspiration with synovial fluid evaluation and tradition is important for the prognosis

Therapy Targets

  • Relieve ache
  • Forestall development
  • Accommodate present deformity
  • Enhance operate
  • Restore articular anatomy (requires surgical correction)


Suggestions for specialist referral

  • Discuss with specialist (eg, orthopedist, podiatrist) for potential surgical intervention when conservative measures fail

Therapy Choices

Therapy consists of conservative (nonsurgical) and surgical measures

Conservative remedy

  • Preferable as first choice
    • Major remedy in juvenile hallux valgus, aged sufferers, and people with extreme neuropathy, vascular compromise, or different comorbidity in whom surgical procedure is contraindicated
  • Doesn’t right the deformity however might enhance signs and performance
  • Modalities embrace:
    • Analgesics (eg, NSAIDs)
    • Footwear alternative: extensive toe field, tender shoe with sufficiently padded insole, avoidance of excessive heels
    • Bodily remedy
      • Could also be helpful alone for delicate hallux valgus, or along with different conservative therapies
      • Can embrace gait coaching, train, handbook remedy, taping, and orthosis
    • Exercise modification
    • Orthotics (shoe inserts)
      • Might present symptomatic reduction in some sufferers
      • Can embrace medial posting (to regulate pronation), metatarsal pad/bar (for switch lesions), bunion flare, and extra-deep shoe with indirect toe field (accommodative)
      • A Cochrane assessment discovered orthoses lowered foot ache after 6 months (in contrast with no remedy) however didn’t scale back foot ache after 6 or 12 months in contrast with surgical procedure in sufferers youthful than 60 years
    • Toe spacers
      • Carrying insole with toe separator might lower ache depth; not efficient in enhancing nice toe angles


  • Symptomatic sufferers in whom conservative remedy fails are candidates for surgical correction
    • Continued ache and dysfunction (disruption of life-style/actions) are indications for surgical consideration
    • Not beneficial for beauty restore in asymptomatic sufferers owing to inherent surgical dangers
    • Principal contraindication is arterial occlusive illness; vague pedal pulses should be evaluated additional
  • Over 150 strategies have been described
    • Variety of surgical procedures partially owing to the a number of components inflicting hallux valgus
    • A Cochrane assessment concluded no approach has been proven to be superior
    • Have to be individualized for every affected person
  • Surgical success is dependent upon selecting finest process for particular person given deformity
    • Guided by cautious analysis of typical radiographs
      • Varied components thought of, together with hallux valgus angle, intermetatarsal angle, distal metatarsophalangeal joint congruity, and presence of arthritis
    • Surgeon’s experience and expertise are components
    • Administration of affected person expectations is necessary; means to put on desired footwear or carry out high-impact exercise must be tempered
      • As much as 41% of sufferers will not be in a position to return to desired footwear selections
    • Choices embrace varied process classes, alone or together:
      • Distal soft-tissue reconstruction
      • First metatarsal osteotomies (distal and/or proximal)
      • Proximal phalanx osteotomies
      • Arthrodesis (fusion)
      • Excisional arthroplasty
  • Postoperative bodily remedy and gait coaching might assist in enhancing operate after surgical procedure

Nondrug and supportive care

  • Affected person schooling
    • Inform sufferers about progressive nature of illness course of in addition to remedy choices and life like objectives

Particular populations

  • Juvenile (pediatric) hallux valgus
    • Comparatively unusual in kids
    • Normally asymptomatic in pediatric inhabitants; sometimes involves medical consideration owing to beauty look of bunion
    • Radiographs, along with exhibiting underlying deformity, present evaluation of epiphyseal plates to help in administration selections
    • Therapy is usually conservative till after skeletal maturity
      • Surgical correction related to excessive recurrence fee and variable scientific outcomes; increased danger of overcorrection
        • Delay is most popular till skeletal maturity until vital ache and deformity intervene with every day dwelling
        • Epiphyseal harm might end in progress disturbance


  • Problems of hallux valgus embrace:
    • Osteoarthritis of first metatarsophalangeal joint
    • Deformation and ache in different digits compelled upward leading to hammer or claw toes
    • Lateral metatarsalgia owing to strain switch from nice toe to lateral metatarsal area
  • Surgical problems embrace:
    • Recurrence (foremost complication)
    • Nonunion
    • Avascular necrosis
    • Hallux varus
    • Switch metatarsalgia
    • Neuromas
    • Hyperesthesia
    • Degenerative arthritis
    • Unmet affected person expectations


  • Left untreated, situation has unsure prognosis
    • Deformity and symptom development could also be speedy in some individuals whereas others stay asymptomatic
  • After acceptable surgical intervention, 85% of sufferers are happy and have good scientific outcome
    • 10% are much less happy, with suboptimal consequence; 5% have poor outcomes
    • Reduction of ache is main goal, however means to put on smaller/narrower footwear is a frequent objective
      • As much as 41% of sufferers are unable to return to desired shoe selections


  • No prevention technique identified; trigger is probably going multifactorial, involving interaction between intrinsic and extrinsic components


Coughlin MJ et al: Hallux valgus: demographics, etiology, and radiographic evaluation. Foot Ankle Int. 28(7):759-77, 2007 Cross Reference